HCA250 W8 Assignment
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PART VII LOOKING TO THE FUTURE
15 WHAT’S AHEAD FOR HEALTH PSYCHOLOGY? Goals for Health Psychology Enhancing Illness Prevention
and Treatment Improving Efforts for Helping Patients Cope Identifying Evidence-Based Interventions and
Cost–Benefit Ratios Enhancing Psychologists’ Acceptance in
Medical Settings
Careers and Training in Health Psychology Career Opportunities Training Programs
Issues and Controversies for the Future Environment, Health, and Psychology Quality of Life Ethical Decisions in Medical Care
Future Focuses in Health Psychology Life-Span Health and Illness Sociocultural Factors in Health Gender Differences and Women’s Health Issues
Factors Affecting Health Psychology’s Future
PROLOGUE ‘‘Oh, this looks very good,’’ the palm reader said as she studied Marty’s hand. She explained: ‘‘Your life line is very long, which usually means you will have a long and prosperous life. At first I thought this break here in the line meant you might have a serious health problem in your 50s, but these lines here at your wrist suggest otherwise. You’ll have a long and healthy life!’’ Marty was relieved. He had come to have his fortune told rather than being tested for HIV. He knew that his past behavior put him at risk for HIV infection, but he couldn’t bring himself to reveal this to the palm reader. Unreasoned behavior is not uncommon when people are very anxious.
Predicting the future is always a chancy enterprise. Still, because the field of health psychology is at an early stage in its development, many people wonder what the field and its goals will be like in the future. This chapter will try to predict what’s ahead for health psychology, and our crystal ball will involve the views of noted researchers and trends that seem clear in recent research. As we consider what the crystal ball suggests, we will try to answer questions you may have about the field’s prospects. What role will future health psychologists play in medical care? Will career opportunities and training programs for health psychologists flourish? How will the field’s goals, issues, and perspectives change? What factors will affect the success and direction of health psychology in the coming years?
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Chapter 15 / What’s Ahead for Health Psychology? 387
GOALS FOR HEALTH PSYCHOLOGY
Health and health care systems around the world have changed dramatically over the last several decades. People in most parts of the world today are living longer and are more likely to develop chronic illnesses than ever before. Many current health problems result from or are aggravated by people’s long-standing habits, such as smoking cigarettes and coping poorly with stress, that medical professionals lack sufficient skills and time to change. The field of health psychology has made enor- mous advances, generating new knowledge and applying information gained from many disciplines to supplement medical efforts in promoting health. Let’s look at some major goals that lie ahead for health psychology.
ENHANCING ILLNESS PREVENTION AND TREATMENT A major issue driving the need for illness prevention around the world is the escalating costs of health care and the need to contain them. The burden of health costs to different nations can be seen in Figure 15-1, which presents health spending as a percent of the gross domestic product for selected countries. As you can see, this burden has risen sharply in the United States since 1980, where health spending is higher and rising faster than in other industrialized nations. We have seen that efforts to prevent health problems should try to reduce unhealthful behaviors. These efforts can be directed toward health-protective activity while the person is well, when symptoms appear, or once an illness is identified and treatment starts.
Health-related behaviors that become features of people’s lifestyles have received a great deal of attention in health psychology. Efforts have been directed toward preventing unhealthful behaviors from developing and changing behaviors that already exist. Unhealthful lifestyles seem to be harder to change than to prevent (Wright & Friedman, 1991). We have seen that psychologists’ efforts to change lifestyle behaviors, such as smoking, exercising, and eating habits, have focused mainly on cognitive and behavioral approaches. Although these approaches are often very effective in producing initial changes, the behaviors frequently revert back to unhealthful patterns later. Relapse is a critical problem that researchers are working to reduce, and it will certainly be an important focus for health psychology in the future.
Once people notice symptoms or are diagnosed with serious health conditions, they often—but by no means always—engage in symptom-based and sick-role behaviors to protect their health. For instance, they may
16 United States
Germany
Canada
Netherlands Sweden
Australia Italy
South Africa
Brazil Average of Seven Industrialized Nations (names in color)
China
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2000 2005/6
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Figure 15-1 Total health expenditures as a percent of the gross domestic product for the specified years. The isolated data points (color) for 2005/6 reflect the most recent available data on expenditures for 13 non-U.S. selected nations. The two line graphs present expenditures for 1980, 1990, 2000, and 2005/6 for the United States (solid line) and the average (dashed line) of the seven industrialized countries of the 13 selected nations. This figure depicts the relative current expenditures across 14 nations and a comparison of the increases in expenditures for the United States and other industrialized countries. (Data for 1980–2000 from NCHS, 2006, Table 119; data for 2005/6 from WHO, 2009,
Table 7.)
go to physicians, take medication, or even follow medical advice that involves changing their lifestyles. Researchers have identified many psychosocial factors that influence whether people will seek health care and adhere to medical regimens. We know, for example, that individuals often decide to reject or delay seeking medical attention because they don’t know the symptoms of serious diseases, such as cancer or diabetes. And people are less likely to adhere to medical advice if the regimens involve complex or long-term behavioral changes and if their physicians do not seem caring or explain the illnesses and treatment clearly. Although we know some methods to reduce these problems, these methods often require extra time or effort that medical professionals are just beginning to incorporate into their practices.
Advances in Research and Theory Health psychologists in the future will continue their search for ways to improve people’s health behaviors
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388 Part VII / Looking to the Future
before illness develops, use of health care services, and disease management after illness develops. New research methods and theories we’ve discussed in this book will promote these efforts. For example, the method called ecological momentary assessment has enabled researchers to examine people’s behavior and feelings in daily life. And theories have appeared that attempt to explain why people do or do not change unhealthful behaviors, building on knowledge gained from earlier theories, especially the health belief model. The stages of change model, which outlines a series of stages in people’s readiness to change health-related behaviors, is an example. This and other theories have generated important research that will contribute to our understanding of ways to promote healthier lifestyles. Research and theory of the future need to expand their focus in at least two ways (Smith, Orleans, & Jenkins, 2004). First, they need to incorporate more levels of factors to represent the biological, psychological, and social systems that work together in affecting health. Second, they need to give more attention to life-span changes in the nature of health threats.
Advances in Technology Technological advances will play an increasing role in preventing and managing illness (Saab et al., 2004). For example, Internet sites have been developed to provide medical information and two-way video and audio communication to individuals in numerous countries and inaccessible areas. This process, called telehealth or telemedicine, provides diagnostic and treatment services and advice on lifestyle changes (Celler, Lovell, & Basilakis, 2003). For instance, a parent can use a device to scan a child’s injured leg and send the image electronically to the hospital where the child had been treated so they can monitor recovery. Because Internet sites for health information vary in quality, they need to be selected carefully (Kalichman et al., 2006). As we saw in Chapter 6, the Internet can also provide software versions of effective psychosocial interventions to improve health.
IMPROVING EFFORTS FOR HELPING PATIENTS COPE Major advances have been made in using psychosocial methods to help people cope with various difficulties in their lives. Stress management programs are being applied widely with nonpatient populations, such as in worksite wellness programs, to help prevent illness.
People with serious medical conditions often must cope with pain, anxiety and fear, and depression. Psy- chosocial interventions are being applied more and more widely with patients in pain clinics, hospitals, and other
medical settings. Years ago, the main function of psychol- ogists in medical settings involved administering and interpreting tests of patients’ emotional and cognitive functioning (Wright & Friedman, 1991). But this situation has changed, and psychologists are focusing much more on a broader array of activities, such as training medi- cal students and interns and applying interventions to help patients cope with illnesses and medical treatment. Health psychologists’ role is likely to continue to expand in hospitals and outpatient rehabilitation programs for people with chronic health problems, such as heart dis- ease and arthritis (Nicassio, Meyerowitz, & Kerns, 2004).
IDENTIFYING EVIDENCE-BASED INTERVENTIONS AND COST–BENEFIT RATIOS Should health care organizations and employers provide psychosocial interventions to prevent illness and help patients cope? Perhaps most people would answer, ‘‘Yes, because it’s the humane thing to do.’’ But with today’s spiraling medical costs, the answer is more commonly based on two factors: the intervention’s efficacy, or degree to which it has the needed effect, and cost–benefit ratio, or the extent to which it saves more money in the long run than it costs (Graham et al., 1998; Kaplan & Groessl, 2002). Bottom-line issues are often weighed heavily in deciding whether to offer wellness or psychosocial programs at work and in medical settings.
Health care professionals recognize the importance of documenting the efficacy of approaches they use, and they do careful research to compare different approaches against each other and control groups. This research is now being used by professionals in medicine and health psychology to identify evidence-based treatments—techniques or interventions with strong efficacy that have clear support across many high-quality studies, particularly randomized controlled trials (Glasgow et al., 2006; Kazdin, 2008). Ideally, the research would have:
• Been carefully evaluated in a meta-analysis or systematic review.
• Assessed the treatment effect’s clinical significance, or meaningfulness for the person’s life and functioning (Sarafino, 2001). The effect is meaningful if the person’s health or behavior has improved greatly or is now at or near the normal or desired level. For example, a treatment that reduces pain intensity by one-third would be meaningful from the patient’s point of view (Jensen, Chen, & Brugger, 2003).
• Conducted follow-up assessments to determine whether the effect is durable.
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Chapter 15 / What’s Ahead for Health Psychology? 389
After evidence-based treatments have been identified for specific conditions or behaviors, professionals need to be apprised of that status and encouraged to adopt and implement those treatments (McHugh & Barlow, 2010). Major efforts are currently underway to accomplish these goals.
Psychologists seldom calculate the financial costs and benefits of interventions. Often the costs of providing an intervention are easily assessed, but the full benefits are not. At a worksite, for instance, what benefits of a wellness program could you assess in dollars to compare with the costs of running it? You might assess worker absenteeism or medical insurance claims, but these variables would reflect only part of the benefits; they wouldn’t reflect other important financial gains, such as increases in workers’ job satisfaction and resulting productivity. In medical settings, measuring the benefits of interventions can be easier—for example, you could assign dollar values to the reduced time intervention patients spend recovering in the hospital and compare these data against the cost of the program.
Many psychosocial interventions for promoting health and helping patients cope have the potential for producing far more financial benefits than costs. More and more evidence is becoming available to document these effects (Aldana, 2001; Kaplan & Groessl, 2002). We considered research in Chapter 10 showing, for example, that hospital patients who receive help in coping with medical procedures recover more quickly and use less medication than those who don’t receive such help. Table 15.1 lists some specific behavioral or and health problems with studies showing that psy- chosocial–educational interventions produced financial savings that were far greater than their costs. Other res- earch has shown that the benefits of worksite wel- lness programs outweigh their costs (Golaszewski, 2001; Matson-Koffman et al., 2005). Although most
psychosocial methods with documented efficacy have not yet been subjected to cost–benefit analyses, health psychologists in the future will probably give much more attention to these analyses than they have in the past. They will also need to develop more effective methods to help people change unhealthful lifestyles—such as for eating healthful diets and exercising—and demonstrate that the benefits of these methods outweigh the costs.
ENHANCING PSYCHOLOGISTS’ ACCEPTANCE IN MEDICAL SETTINGS A woman wrote an article in the late 1980s and described her experience when she developed breast cancer. Her physicians advised her to get treatment from a variety of medical professionals but
at no point did anyone in the medical fraternity recommend that I see a mental health professional to help me cope with the emotional impact of breast cancer. Perhaps they didn’t realize that breast cancer had an emotional impact. But I did. So, I went to see a psychologist, ironically the one specialist not covered by my insurance. It was worth the cash out of pocket. (Kaufman, cited in Cummings, 1991, p. 119)
Although gaining acceptance by the medical profession has progressed steadily since the 1980s, it continues to be a challenge for health psychology (Belar & McIntyre, 2004).
Part of the difficulty health psychologists have faced in gaining acceptance in medical settings stems from their past role and training. Before 1970, psychological services were usually seen as tangential to the medical needs of most patients, and psychologists had little or no training in physiological systems, medical illnesses and treatments, and the organization and protocols of
Table 15.1 Psychosocial–Educational Interventions with Very Favorable Cost–Benefit Ratios for Reducing Specific Behavioral and Health Problems
Problem Population Studies
Behavior Drinking Men and women, general Cobiac et al., 2009; Fleming et al., 2000 Drug abuse Clients in residential treatment French, Salome, & Carney, 2002 HIV transmission HIV-positive youth Lee, Leibowitz, & Rotheram-Borus, 2005 Smoking Men and women, general Alterman, Gariti, & Mulvaney, 2001; Curry
et al., 1998 Smoking Pregnant women Windsor et al., 1993
Health Arthritis Elderly men and women patients Cronan, Groessl, & Kaplan, 1997 Asthma Children and adult patients Liljas & Lahdensuo, 1997 Back pain Employee patients Jensen et al., 2005; Turk, 2002 Heart disease Men patients Blumenthal, Babyak et al., 2002; Davidson
et al., 2007
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390 Part VII / Looking to the Future
hospitals. But these conditions have changed. Today, health psychologists are receiving the training they need to work effectively in medical settings. And more and more physicians are coming to recognize the importance of psychosocial factors in their patients’ health, adher- ence to treatment regimens, and rehabilitation. They also realize that they do not have the skills or time to address many of these factors.
Initial relations between medical staff and health psychologists still tend to be strained in some settings, particularly when one function of the psychologist may be to teach physicians and interns the ‘‘people skills’’ that are important for interviewing patients and communicating with them effectively. This kind of training may get a mixed reception, especially from some medical staff who feel that these skills are not part of medicine (Christensen & Levinson, 1991). Even after medical and psychological staff have collaborated for a long time and seen that a biopsychosocial approach to health care can benefit patients, be intellectually stimulating, and lead to developing new techniques, their different styles and points of view can lead to conflicts (McDaniel & Campbell, 1986). For example, psychologists generally want to talk directly with the attending physician to describe subtle and complex issues relating to a patient’s treatment plan, but medical specialists typically communicate with each other in writing, such as with notes in a hospital chart. Differences like these can be resolved. Medical education guidelines now promote the training of physicians to include skills in teamwork and partnering with professionals in nonmedical fields (Belar & McIntyre, 2004; Daw, 2001).
What about patients—how do they feel about receiving psychological services? Their view is likely to depend on the way the physician and psychologist introduce these services. If a patient thinks the services are offered because his or her physician thinks he or she is ‘‘crazy’’ or that the problem ‘‘is all in your head,’’ the patient is likely to have negative attitudes and fail to cooperate. People are more likely to view psychosocial interventions positively if the services are
introduced as part of a standard ‘‘team approach’’ with a biopsychosocial orientation. (Go to .)
CAREERS AND TRAINING IN HEALTH PSYCHOLOGY
Most health psychologists follow one of two career categories: working mainly in clinical capacities with patients or working mainly in academic or research capacities (Belar & McIntyre, 2004; Sweet, Rozensky, & Tovian, 1991). Many health psychologists have careers that combine these areas, being involved in both clinical and academic or research activities, and some do administrative work, such as in governmental agencies or programs to promote health.
CAREER OPPORTUNITIES The opportunities for careers in health psychology in the United States have been good, especially in health care settings. In the early years, the number of psychologists working in health care more than doubled from about 20,000 in 1974 to over 45,000 in 1985 (Enright et al., 1990). Career opportunities have continued to grow since then. States have passed laws enabling psychologists to obtain full staff status in hospitals, giving them the same privileges as physicians. The current outlook for the next decade is for strong job growth for psychologists, particularly those with a doctoral degree in fields related to health (USDL, 2010).
Besides hospitals, where else do health psycholo- gists work? Some of the more prominent sites are:
• Colleges and universities
• Medical schools
• Health maintenance organizations
• Rehabilitation centers
• Pain clinics
• Private practice and consultancy offices
CLINICAL METHODS AND ISSUES
Psychologists in the Primary Care Team In the late 1990s, some American
managed-care programs, such as HMOs, began to include psychologists as members of the medical care team (D. Bruns, personal communication, September 1, 1998). Why? Program administrators came to realize that psychological factors, such as stress and emotional
problems, play a pivotal role in the symptoms most patients present in their health care visits. Primary care psychologists evaluate these patients’ needs and provide help, such as with brief counseling or training to improve adherence to treatment recommendations or manage stress or pain (McDaniel & Fogarty, 2009).
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Chapter 15 / What’s Ahead for Health Psychology? 391
Sometimes job descriptions for these settings are broad, making eligible professionals from nonpsychology fields, such as nursing, public health, or social work. Although this can increase the competition for those jobs, broad job descriptions can increase the number of opportunities for psychologists, too.
TRAINING PROGRAMS What kind of training is available and necessary in health psychology? Training is offered at three educational levels: undergraduate courses in health psychology or behavioral medicine, graduate programs, and postdoctoral programs. Because health psychologists typically hold doctoral degrees, dozens of graduate programs now exist in the United States and other countries specifically for that training. Postdoctoral programs are available in health psychology or behavioral medicine, particularly for people with doctoral degrees that did not focus on the relationship between health and psychology.
Graduate training programs in health psychology are diverse (Belar & McIntyre, 2004; HP, 2010). Some are highly interdisciplinary programs that are designed solely for this field. They often specialize in training students either for research careers or for direct clinical service to patients. Other programs provide graduate training in traditional psychology areas, such as clinical or social psychology, and contain special tracks or emphases relating to health. Common to all these programs is a solid grounding in psychology, along with training in research methods, biopsychosocial processes in health and disease, and health care terminology and organization. Programs that educate students for direct clinical service to patients generally include medical courses, such as in physiology and pharmacology. The future may see greater standardization of health psychology training programs in the United States and around the world, based on the identification of specific core competencies that clinical health psychologists should have when they enter the profession (France et al., 2008).
Information about graduate and postdoctoral train- ing programs in health psychology can be obtained by contacting the following professional organizations:
• American Psychological Association, Division of Health Psychology, 750 First Street N.E., Washington, DC 20002- 4242 Web Page: http://www.health-psych.org (the Education and Training page has a Find Training Programs database)
• Society of Behavioral Medicine, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202-3823 Web Page: http://www.sbm.org
The European Health Psychology Society (http:// www.ehps.net) is a professional group for researchers and practitioners; the delegates they list may be able to suggest training programs in their specific countries.
ISSUES AND CONTROVERSIES FOR THE FUTURE
Findings from research and clinical experience will enable health psychologists to help societies resolve important issues and controversies in the future. We will look at several examples, beginning with the impact of environmental conditions on health and psychology.
ENVIRONMENT, HEALTH, AND PSYCHOLOGY Each of the environments in which people live around the world contains conditions that have the potential to harm or benefit the health and psychological status of its inhabitants. For example, some communities contain barriers to physical activity; they can encourage activity by changing land-use and residential density policies (Sallis et al., 2006; Salmon et al., 2003). We also read and hear in the news media that the environment is becoming increasingly polluted with toxic substances, released accidentally or deliberately into the air, ground, or bodies of water. The environments in which people live are also becoming more crowded and noisy. What effects do these conditions have? How can we reduce harmful environmental conditions? Some answers use a public health approach: because cigarette smoke pollutes the air and can lead to illnesses in those who breathe it, some psychologists have called for governmental control of tobacco products (Cummings, Fong, & Borland, 2009; Kaplan et al., 1995).
Many toxic environmental pollutants are produced as byproducts either of manufacturing or of generating energy. For instance, some manufacturing industries produce highly toxic cyanide or mercury as byproducts, which have made their ways into the environment. What direct effects on health does long-term exposure to low levels of pollutants have? How stressful is it to live or work in contaminated environments, and how much does this stress affect health? How much does the stress of crowding and noise affect health? Health psychologists can help in efforts to answer these questions and find ways to change behaviors that produce these problems (Weinman, 1990). Although we have some information on these questions, much more research will be needed in the future before we can provide accurate answers.
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392 Part VII / Looking to the Future
QUALITY OF LIFE People’s quality of life has become a significant issue in medical care because (1) it is reduced by becoming sick and by staying sick and (2) it is an important consideration in prevention efforts before and after an illness occurs. Efforts to maintain people’s good health also maintain their quality of life, and efforts to help patients recover quickly and fully lessen the negative impact of the illness on their lives. For people who are ill, their quality of life enters into decisions about the medical and psychological treatment they will receive. Are they in pain? If so, what type of painkilling medication should they get, and how much? If they’re distressed, what psychosocial methods are likely to improve their emotional status?
Life-or-death medical decisions are often heavily influenced by appraisals of patients’ current and future quality of life. Current quality of life is especially important if there is virtually no hope of the patient’s recovery. In such cases, the views of the patient, family, and medical staff are likely to come down to a judgment of whether living in the current state is better than not living at all. Future quality of life is important in medical decisions that can enable the patient to survive, but will leave him or her with seriously impaired physical, psychological, and social capacities. For example, the family of an elderly man with a disabling cardiovascular condition felt he would be better off not living
if he was just going to be a vegetable. They said his whole life revolved around working in his yard and playing bridge; these were the things in life that gave him joy. Now the doctors were not giving any hope that he would ever get back to what he was before; the best that could be hoped for was that he would be able to sit in a wheelchair. They said they didn’t want that for him, and … he wouldn’t want that for himself either. (Degner & Beaton, 1987, p. 64)
Decisions to withhold heroic medical efforts clearly involve humane concerns, but financial considerations are important, too (Spurgeon et al., 1990). Heroic medical efforts and aftercare are extremely expensive. With the enormous pressures to contain the cost of health care, are these expenses always justified even when the resulting quality of life will be poor?
Making medical and psychological decisions based on a patient’s current or future quality of life is difficult, partly because researchers need to determine the best ways to measure it. One approach that some people favor to help make these decisions uses a scale called quality- adjusted life years (QALYs, pronounced ‘‘KWAL-eez’’). To
calculate the QALYs for a medical treatment, we would assess how long a person is likely to live after receiving the treatment, multiply each year by its quality of life, and total these data (Bradley, 1993; Kaplan, 2004). Using QALYs, we could rank the value of different treatments for a particular person or in general, perhaps even taking the cost per QALY into account, and decide whether to provide the treatment. At the heart of this approach is the measurement of quality of life. Although there are dozens of questionnaires to assess quality of life, the qualities they measure vary widely (Gill & Feinstein, 1994; Kaplan, 2004). Which should we use? Health psychologists will play an important role in resolving how best to use quality of life assessments in making treatment decisions.
ETHICAL DECISIONS IN MEDICAL CARE Suppose you were an obstetrician delivering a baby when you realized that complications you see developing will surely kill the baby and, maybe, the mother, too. Suppose also that the mother flatly refuses a Caesarean delivery for religious reasons. What do you do? One medical response might be to seek an immediate court order to override her decision. The decisions made in this case and the quality of life decisions we just considered all involve ethical issues. Many hospitals today have bioethics committees to discuss ethical issues in health care, make policy, and recommend action regarding specific cases. The ethical issues these committees consider often involve the patient’s right to choose treatments, to withhold or withdraw treatment, or to die (Bouton, 1990). We will examine two other important issues: the role of technology in medical decisions and the role of physicians in helping patients die.
Technology and Medical Decisions The technological advances we have seen in our lives over the past few decades have been quite remarkable. Many of these advances have been in medical technology, and they have sometimes raised important ethical questions.
One of these technological advances is a computer program that calculates the odds that individual patients will die in intensive care or after they leave it (Seligmann & Sulavik, 1992). Why might this be a problem? Decisions about whether intensive care treatment will help the patient survive are made every day, based on physicians’ broad estimates, such as, ‘‘Her chances look bleak.’’ With the computer program, physicians can get precise estimates of the person’s odds of dying if he or she continues in intensive care, say 42%, versus if he or she
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Chapter 15 / What’s Ahead for Health Psychology? 393
is transferred, say 78%. In this example, transferring the patient would greatly increase the odds that he or she would die. The comparison helps in making the decision. The ethical problems relate to how these numbers will be used. Should physicians tell families these numbers? Will physicians and families weigh these data too heavily in their decisions? Will hospitals release these data to insurance companies, which could then decide to limit coverage when scores drop below some level? Health psychologists can play a role in some of these decisions, especially those relating to families having and using these data (Weinman, 1990).
Other ethical dilemmas arise in deciding whether to provide an organ transplant for patients. Nearly 28,000 transplants are done each year in the United States (USBC, 2010). Health psychologists help medical practitioners to select candidates who are best able to benefit from the surgery and the scarce organs because these people are able to cope with the stress and behave appropriately to maintain their health with the new organ. To help make these decisions, psychologists screen potential candidates—some patients will be clearly up to the task, and some will not, such as candidates for liver transplant who have not been able to control their drinking. Others will be in between and may benefit from interventions of behavioral contracting and therapy to help them cope better (Dew et al., 2004; Olbrisch et al., 2002).
Advances in genetics technology may also present ethical problems. For instance, geneticists can identify individuals who are likely to develop serious diseases, such as cystic fibrosis and some forms of cancer, and may soon be able to identify individuals who are vulnerable to environmental causes of cancer and heart disease (Detjen, 1991; Lerman, Audrain, & Croyle, 1994). Who should be tested for these risks, and who should have access to the results? Insurance companies would like this information, and some are already turning down applicants for insurance on the basis of known family histories of certain diseases.
Assisted Dying: Suicide and Euthanasia Some people with serious illnesses come to the decision that they want to end their lives. Should physicians help them in their wishes? This is a very controversial issue for society in general and in the medical community (Miccinesi et al., 2005). Among physicians, some feel they should not help because of certain beliefs they hold, such as that life is sacred or that medical workers should only save lives and not take them. Other doctors feel they should participate in this act if the patient
is actually beyond all help and the decision was not made because of psychological depression that could be reduced (Sears & Stanton, 2001). Most terminally ill people who are interested in ending their lives are mainly worried about future pain and loss of autonomy and function (Ganzini, Goy, & Dobscha, 2009). Others who want to end their lives are depressed and may change their minds if the depression is relieved (Ransom et al., 2006; Zisook et al., 1995).
Some physicians have helped patients end their lives in two ways (Rosenfeld, 2004; Sears & Stanton, 2001). In assisted suicide the patient takes the final act, but the physician knowingly prescribes the needed drugs or describes the methods and doses required. Because of the legal consequences for physicians who help people take their lives, a book called Final Exit was published in 1991 describing procedures physici- ans would recommend. In euthanasia the physician (or someone else) takes the final act, usually by admi- nistering a drug that ends the life. Laws permit euthana- sia in the Netherlands and physician-assisted suicide in Oregon under carefully specified and monitored circumstances. When societies decide that it is accept- able for physicians to help a patient end his or her life, laws can require psychological assessment of the person’s emotional status, ability to make sound deci- sions, and likelihood of benefiting from psychosoc- ial intervention (Sears & Stanton, 2001). (Go to .)
FUTURE FOCUSES IN HEALTH PSYCHOLOGY
The research that contributes to our knowledge in health psychology comes from many different fields. But early studies gave a relatively narrow view of the biopsychosocial processes involved in health and illness because of the people researchers tended to recruit as subjects: in studies of Type A behavior, for example, they often were 18- to 60-year-old white American males. Two reasons for this focus are that these people were readily available and some researchers incorrectly believed that the findings would easily generalize to other populations. In the 1980s, studies began to focus on including subjects representing a wider range of people. This trend will surely continue in the future.
LIFE-SPAN HEALTH AND ILLNESS We’ve seen that the health problems people have and the extent to which they use health services change with age. Very young and elderly individuals use health
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394 Part VII / Looking to the Future
ASSESS YOURSELF
Some Ethical Dilemmas: What Do You Think? Each of the following cases describes
a decision involving an ethical dilemma that is related to health. Circle the Y for ‘‘yes’’ or the N for ‘‘no’’ preceding each case to indicate whether you agree with the decision.
Y N A 47-year-old woman developed cirrhosis of the liver as a result of long-term alcoholism. She promised to stop drinking if she could receive a liver transplant. Her request was denied because of likely future drinking.
Y N An overweight, chain-smoking, sedentary 51-year-old man with high blood pressure had his first heart attack 7 years ago. His request for a heart transplant was denied because of continuing risk factors.
Y N A 28-year-old married woman with a heredi- tary crippling disease that is eventually fatal decided to become pregnant, knowing that there was a 50% chance that she would pass on the disease to her baby and she would not consider having an abortion.
Y N A 37-year-old executive was told by his boss that he would have to pay half of the costs of his employer-provided health insurance
if he did not quit smoking and lower his cholesterol.
Y N An obese 20-year-old woman who refused to try to lose weight was expelled from nursing school, despite having good grades and clinical evaluations, because it was said she would ‘‘set a poor example for patients.’’
Y N State workers are assessed an extra health insurance fee each month if they smoke cigarettes or are overweight because people with these statuses generate far higher medical expenses than other employees do.
Y N A 30-year-old woman was denied a promo- tion to a job that involved working in an area with gases that could harm an embryo if she were to become pregnant.
Y N A year after a boy developed leukemia, the company that provided his family’s health insurance quadrupled their premium.
These dilemmas are all based on real examples from the news media. Because they all involve controversies, there is no key to the ‘‘right’’ answers. But you might want to ask friends or classmates what they think.
services more than others do. Populations are aging rapidly around the world, which will lead to health care challenges in the future.
From Conception to Adolescence Children’s prenatal environments have a major effect on their health. Enormous numbers of babies are born each year with illnesses or defects that develop because of prenatal exposure to harmful conditions or chemicals, particularly when mothers use alcohol, drugs, or tobacco during pregnancy. The health problems these babies develop can last for years or for life. Health psychologists study ways to improve babies’ prenatal environments, such as by educating and counseling prospective parents (Weinman, 1990). Although these approaches help, we need to find more effective ways to prevent these health problems from developing.
Childhood and adolescence are important periods in the life span because many health beliefs and habits form during these years (Smith, Orleans, & Jenkins, 2004). But very little research has examined how these beliefs
and habits develop. We do know that efforts to promote health should be introduced early, before unhealthful beliefs and habits develop. Early childhood is clearly the time to intervene for some behaviors, such as for proper diets, exercise, dental care, and seat belt use. In later childhood, interventions should focus on preventing accidents, cigarette and drug use, and unsafe sex. We saw in Chapter 7, for example, that programs to prevent children from starting to smoke cigarettes have had some success. We have also seen that behaviors that put people at high risk for AIDS can be changed substantially, thereby reducing their risk. Efforts to prevent the spread of HIV need to be intensified and applied worldwide. To design more effective health promotion programs, we will need to focus more research—especially longitudinal studies—on how health behaviors form and change in childhood and adolescence.
Adulthood and Old Age By the time people reach adulthood, most health-related values and behaviors are ingrained and difficult to
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Chapter 15 / What’s Ahead for Health Psychology? 395
change. People’s lifestyles during the early adulthood and middle-age years tend to continue and affect whether or when they will develop major chronic illnesses, particularly heart disease and cancer. The earlier people change unhealthful behaviors, the lower their health risks are likely to be. In addition, prolonged emotional difficulties, particularly depression, are linked to future illness, such as heart disease. Among elderly people equated for initial physical health, those who are depressed show sharper physical declines, such as in walking speed, over the next few years than nondepressed elders do (Penninx et al., 1998).
As the world population ages, the proportion of individuals with disabling or life-threatening illnesses will surely grow, requiring more health services and psychosocial interventions. This will be compounded if life expectancy increases (Sierra et al., 2009). In the United States, an unusually high birth rate after World War II created a very large generation of people called ‘‘baby boomers,’’ who are starting to swell the ranks of the elderly. Figure 15-2 shows the aging trend in America: the elderly are becoming an increasingly large portion of population. This trend means that health care costs will increase sharply in the future. How will health care systems around the world respond to the added loads? This potential makes it even more crucial that we find ways to prevent or change risky lifestyles, particularly with regard to diet, exercise, and substance use. We will also need to improve ways to help families cope with the difficulties of caring for elderly relatives. The number of studies dealing with health issues in old age published each year has increased since 1980 and will continue to be a major focus of health psychologists in the future.
SOCIOCULTURAL FACTORS IN HEALTH Sociocultural differences in the United States and around the world are related to health and health behavior. For instance, Americans from the lower social classes and from Black and Hispanic minority groups tend to have poorer health and health habits than Whites and those from higher classes. These differences have been clear for a long time. Although researchers have begun to investigate why these differences exist and what can be done to reduce them, our knowledge on these issues is not very specific. For example, we don’t know how cultural customs and socioeconomic factors shape the everyday lives of different ethnic groups (Anderson & Armstead, 1995; Yali & Revenson, 2004). And so we tend to make broad conclusions, as when we say people in a minority group ‘‘live in environments that do not encourage the practice of health-protective
1950
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Figure 15-2 United States population at 1950, 2000, and 2050 (projection), with portions consisting of elderly age groups designated and percent of people 65 and older specified. (Data from NCHS, 2009a, p. 111.)
behavior.’’ Health psychology must give greater emphasis to sociocultural issues so that we can provide specific and useful solutions in the future.
Cross-cultural research also needs more emphasis. We have spotty information about cultural differences in lifestyles, perceiving symptoms of illness, and using health services, and most research on these differences is old and very incomplete. Although some books and journal articles address ethnic differences within countries, especially the United States, few examine differences across countries (Kazarian & Evans, 2001). In the poorer nations of the world, such as in African and Eastern Mediterranean regions where infectious diseases and malnutrition are often rampant, it is not unusual for 10–15% of children under the age of 5 to die each year (WHO, 2009). The number of people infected with HIV in Africa and other developing areas of the world is astounding and growing rapidly. The countries with the most urgent need to change behavioral risk factors have not yet recognized that principles of health psychology can help promote public health. In addition, health psychologists need to conduct research to determine how to adapt the principles that work in the United States and other industrialized countries to the needs of other cultures.
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396 Part VII / Looking to the Future
GENDER DIFFERENCES AND WOMEN’S HEALTH ISSUES Health issues relating to women and gender differences were also neglected in health psychology research until the 1980s. Since that time, studies have examined women’s health behaviors, such as diet, smoking, and exercise; cardiovascular and pain disorders; and issues that are specific to women, such as screening for cervical and breast cancer (Revenson & Jeltova, 2004; Rimer, McBride, & Crump, 2001). Research has also studied differences between males and females in a wide variety of characteristics, such as reactions to stress, Type A and B behavior patterns, risk of AIDS and of heart disease, weight regulation, and tobacco and alcohol use. Gender- related research has become a main focus of health psychology today and for the future. This research is making clearer the uniqueness of women and men in their health and health-protective behaviors and the special interventions they are likely to need to promote their health.
FACTORS AFFECTING HEALTH PSYCHOLOGY’S FUTURE
The picture of health psychology’s future that we have considered is based on trends and needs that can change in the future. The prospects for our discipline will depend on forces and events in society, medical fields, and psychology. What factors are likely to affect the role and direction of health psychology in the future?
Some factors can have a broad impact on health psychology, affecting the amount and type of research, clinical intervention, and health promotion activities that we do. One of these factors is monetary (Tovian, 2004): how much financial support will there be for these activities? During hard economic times, cutbacks in governmental and private funding may reduce this support. But there is another side to this coin—health care costs around the world are increasing, and many health experts believe that two of the best ways to decrease these costs involve improving people’s health behaviors and helping those individuals who become ill
to recover quickly. We’ve seen that health psychologists can help reduce costs in both of these ways. Funding will also depend on how health insurance and services are structured. Health care systems are changing rapidly in many countries. The changes that emerge will probably continue or strengthen support for psychosocial interventions with favorable research evidence regarding their cost–benefit ratios.
Another factor that can have a broad impact on health psychology’s future is education and training in this discipline (Weinman, 1990). Undergraduate courses in health psychology can reach students from various nonpsychology fields, such as nursing, premed, and sociology. Students who have a positive view of the role and success of health psychology are likely to promote its research, application, and interdisciplinary contacts in the future. If these students go into medical fields, they are likely to be receptive to learning about psychosocial methods by which they and health psychologists can promote the health of their patients. These circumstances can enhance acceptance of health psychologists in medical settings.
Developments in medicine will also influence the future of health psychology (Weinman, 1990). New and growing health problems generally require psychosocial interventions to reduce people’s risk factors for these illnesses and help patients and their families cope. This can be seen clearly in the role of health psychology in addressing these kinds of issues in AIDS and Alzheimer’s disease, for instance. Health psychologists often have an important role to play when new medical treatments are found, particularly if these treatments are unpleasant or if they may impair the patient’s quality of life.
As you can see, many factors can affect the future of health psychology. The field has made dramatic and rapid advances in its short history, but we still have much to learn. Although we sometimes head in the wrong direction, we can take heart and humor from the following perspective:
Life is a test, It is only a test. If this were your actual life, You would have been given better instructions! (Anonymous, cited in Pattishall, 1989, p. 47)
SUMMARY
Major changes have occurred in health and health care systems around the world in the past several decades. People are living longer today and are more likely to develop chronic illnesses that result from or are aggravated
by their longstanding health habits. Health psychology has made major advances in helping to prevent or change these behaviors. The field has also developed effective psychosocial methods to help patients and their families
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Chapter 15 / What’s Ahead for Health Psychology? 397
cope with chronic illnesses, and some of these methods have been identified as evidence-based treatments. For many interventions health psychologists use, research has also demonstrated favorable cost–benefit ratios. These successes have helped to promote the acceptance of health psychologists in medical settings.
Career opportunities for health psychologists have expanded rapidly, and the employment outlook for the future continues to look good. The availability of training in health psychology has grown at the undergraduate, graduate, and postgraduate levels. This training is solidly based in psychology and includes a substantial amount of information on biopsychosocial processes in health and illness and on medical terminology and procedures.
Health psychology has begun to address important health issues and controversies that societies will need to resolve in the future. These issues and controversies include the impact of environmental factors on people’s health and psychological status, patients’ quality of life, and ethical decisions in medical care. Some ethical questions relate to the use of technological advances in health care and whether physicians should participate in helping hopelessly ill patients end their lives. Health psychology has also begun to focus its attention on life-span, sociocultural, and gender issues in health. Forces and events in society, medicine, and psychology will affect the future role and direction of health psychology.
KEY TERMS
cost–benefit ratio evidence-based treatments
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